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Internal Med > Ischaemic Heart Failure > Flashcards

Ischaemic Heart Failure Flashcards

1
Q

What are the 3 types of IHD?

A
  1. Unstable angina pectoris
  2. Non-ST elevated Myocardial infarction
  3. ST elevated myocardial infarction
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2
Q

What is acute coronary syndrome?

A

It is myocardial ischaemia or infarction caused by occlusion of the coronary arteries

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3
Q

What are the causes of decreased perfusion to myocardial tissue?

A
  1. thrombus(most common cause atherosclerosis)
  2. embolus
  3. spasm
  4. trauma
  5. congenital
  6. syphillis
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4
Q

What causes decreased supply of oxygen to the heart?

A
  1. Anaemia
  2. Hypotension
  3. Cyanotic conditions
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5
Q

What causes increased demand fro the heart?

A
  1. thyrotoxicosis
  2. pregnancy
  3. hypertension
  4. aortic stenosis
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6
Q

What is the pathophysiology of Ischaemic Heart disease?

A
  • there is first a stable atherosclerotic plaque
  • this has a fibrous cap over the lipid filled lesion
  • There are inflammatory enzymes like macrophages that release proteins that cause rupture of the fibrous cap and exposes the thrombogenic lipid core whic forms a thrombus
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7
Q

What is partial coronary artery occlusion?

A

Common in unstable angina and NSTEMI and is because of the decreased myocardial blood flow that causes myocardial ischaemia particularly in the subendocardial tissue

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8
Q

What is complete coronary artery occlusion?

A

It is common in STEMI’s this is where there is a transmural infarction

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9
Q

Describe unstable angina?

A

-This presents as not severe enough to cause ECG changes as well as biochemical markers

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10
Q

Describe NSTEMI?

A

-This presents as myocardial injury that is severe enough to cause ECG changes and biochemical markers

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11
Q

Describe STEMI?

A

Myocardial infarction severe enough to cause ST changes and biochemical markers

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12
Q

What are the ECG findings you find in NSTEMI?

A

-no changes or ST depression with loss of the R wave or T wave inversion

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13
Q

What are the ECG findings you find in STEMI?

A

-ST elevation in two contigious leads and Left bundle branch block

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14
Q

What are the imitators of NSTEMI?

A
  • infection with fever
  • Anemia with Hb<10
  • uncontrolled heart failure
  • increased exercise and activity
  • increased emotional stress
  • hyperthyroidism
  • vasoconstriction
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15
Q

What is the clinical features of NSTEMI and unstable angina?

A
  1. crescendo angina(severe, persistent angina)
  2. Angina at rest
  3. Autonomic dysfunction-syncope, diaphoresis, nausea and vomiting
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16
Q

What are the different iso-enzymes of creatinine kinase?

A
  1. BB-brain and kidney
  2. MB- skeletal muscle and heart muscle
  3. MM-heart muscle
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17
Q

What is are the causes of false positives of troponin t?

A
  1. myocarditis/pericarditis
  2. stroke
  3. acute renal failure
  4. burns >30%
  5. chemotherapy
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18
Q

When does troponin T peak?

A

12-24 hours

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19
Q

When does Troponin normalise?

A

7-10 days

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20
Q

What are the biochemical markers we use in ACS?

A
  1. troponin T/I
  2. myoglobin but not used regularly
  3. CK-MB which is more specific than total creatinine which can also be helpful in determining reinfarcts because of the short half life
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21
Q

What is the management of NSTEMI/unstable angina?

A
  1. Admit the patient in ICU
  2. Start the patient on:
  3. dual antiplatelet therapy: aspirin and clopidogrel for a minimum of 6 months
  4. salicylates
  5. Beta blockers(atenolol) aim to get the HR <70bpm
  6. statin to keep the LDL <2,5
  7. Intravenous heparin or low molecular weight heparin subcutaneoulsy
  8. Nitroglycerin
  9. ACE inhibitors
  10. glycoprotein IIb/IIIa receptor antagonists
  11. Clexane
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22
Q

What are the two ways we can risk startify patients?

A
  1. TIMI score

2. Grace 2.0 risk calculator

23
Q

What are the scores for the TIMI score?

A
  1. TIMI score 1: low risk so patient must do exercise ECG and be discharged early
  2. TIMI score 2-4: intermediate risk- and requires admission for full treatment of ACS
  3. TIMI score >5 early angiography and intervention
24
Q

What are the characteristics on the TIMI score?

A
  1. > 65 years
  2. elevated cardiac biomarkers
  3. > 3 risk factors like hypertension, family history, smoking, hypetension, hyperlipidaemia
  4. Previous coronary artery disease (>50% prior stenosis)
  5. ST elevation >0,5mm
  6. 2 Angina’s in the past 24 hours
  7. use of salicylates in the past 7 days
25
Q

What constitutes categorising a patient as very high risk? Angiogram must be done within 2 hours

A
  1. Haemodynamically unstable
  2. ventricular tachys
  3. recurrent dynamic changes on ECG
  4. acute heart failure
  5. 48 hours of medical management and no improvement
26
Q

What are the characteristics of high risk patients? Needs angiogram within 24 hours?

A

-All NSTEMI’S
-ST depression on ECG
TIMI score >5

27
Q

What are the characteristics of intermediate risk? Angiogram can be done in 72 hours

A
  • Patients must have had previous coronary artery bypass
  • coronary stent in the last 2-12 months
  • poor pre-discharge stress ECG
28
Q

How long is it very NB to try and save the myocardium?

A

20 minutes, after that and particularly after 90 minutes we can try to salvage the myocardium

29
Q

When is the myocardial tissue completely dead?

A

after 24 hours

30
Q

What side room tests do you do in STEMI?

A
  1. Temperature >fever
  2. raised white cell count
  3. raised ESR may be present after 1 day
31
Q

What is the clinical features of STEMI?

A
  1. Pfodromal symptoms: tiredness or signs of unstable angina occurring 20-60% a couple of days or weeks before the attack
  2. Auscultation: S4 because of reduced compliance of the left ventricle, S3 because of left ventricle dysfunction
  3. Acute restrosternal angina of longer duration 2-3 hours and even 12 hours
    Commonly radiates to left chest, arm, shoulder, neck, jaw, and/or epigastrium
    Precipitated by exertion or stress
    Dyspnea (especially with exertion)
    Pallor
    Nausea, vomiting
    Diaphoresis, anxiety
    Dizziness, lightheadedness, syncope
32
Q

What are the 2 common things that kill patients commonly?

A
  1. cardiogenic shock

2. arrythmias

33
Q

What are the special investigations we do in STEMI?

A
  1. ECG’s
  2. biomarkers
  3. coronary angiogram
  4. cardiac MRI
    - new and expensive
  5. transthoracic echocardiogram
34
Q

What is lysis?

A

This is thromobolysis where we give the patients medication that will break down the clot to prevent further myocardial infarction before we can take the patient to get a PCI

35
Q

When is lysis contraindicated?

A
  • In patients with previous intracranial haemmorhage or stroke of unknown origin
  • Ischaemic stroke in the preceding 6 months
  • known bleeding disorder
  • gastrointestinal bleeding within the past month
36
Q

After lysis how can we tell that the vessel is open?

A
  1. No chest pain
  2. ST elevation has resolved by 50%
  3. Haemodynamic and electrical stability
37
Q

What do we do if the patient was not successfully lysed?

A

We have to do a rescue PCI

38
Q

When do we give the patient oxygen mask?

A

If the SATS are less than 90%

39
Q

Should we give the patient morphine?

A

We can but we need to ensure it is only between 2-4ml because too much can mask the pain and that is what we use to determine the efficacy of lysis

40
Q

Why do we do an angiogram in patients that we have successfully lysed?

A

To assess the risk of re-occlusion

-This is basically because there can be VT/VF(which can kill you) and loss of muscle

41
Q

What is Wellens syndrome?

A 
type a:  biphasic T wave
type b: deeply inverted T wave
particularly in V2-3 and sometimes V1-6
-History of angina
usually occlude LAD and present with anterior STEMI
42
Q

How do we risk stratify patients that present with ACS but without ST elevation?

A
  1. Any of the emergency indications
  2. Wellens syndrome
  3. cardiac enzymes
  4. dynamic ST deviation
43
Q

What is the differential diagnosis of Wellens syndrome?

A

LVF

44
Q

What are type 2 infarcts?

A

This is when there are multiple risk factors, with chest pain and a precipitating event but is not caused by plaque rupture

45
Q

Why do we use dobutamine in patients?

A

This is to increase the blood pressure if the patient is hypotensive

46
Q

What is the management plan for a patient with STEMI presenting acutely?

A
  1. First point of contact do ECG within 10 minutes, if ST elevation either start thrombolysis or emergency PCI rescue
  2. The thrombolysis we give is streptokinase
  3. Then give dual antiplatelet therapy with aspirin and clopidogrel for a year
  4. Give anticoagulant like heparin until angiogram is done
  5. Correct hypotension with dobutamine if <90mmHg systolic pressure or intravenous fluids
  6. Primary PCI rescue PCI
  7. Give beta bockers: reduces tachyarrythmias
  8. Morphine 10mg in 10ml to give as a analgesic and sedative
47
Q

What is PCI?

A

Percutaneous coronary intervention

48
Q

What does an echo do?

A

It gives an estimation of the damage that occurred to the LV

49
Q

What is the lifelong treatment that the patients have to use?

A
  1. salicylates
  2. clopidogrel fo 6-12 months
  3. beta blockers for life
  4. ACE inhibitors if there’s a significant area of infarction
  5. statin to keep the LDL below 1,8
50
Q

What are the complications within 0-24 hours past the myocardial infarction?

A
  1. sudden cardiac death
  2. Arrythmias
  3. cardiogenic shock
  4. Acaute left heart failure leading to pulmonary edema
51
Q

What are the complications within 1-3 days?

A
  1. Pericarditis
52
Q

What are the complications within 3-14 days?

A
  1. Papillary muscle rupture
  2. Ventricular septal rupture
  3. Left ventricular free wall rupture
  4. Left ventricular pseudoaneursm
53
Q

What are the complications 2 weeks to months post infarction?

A
  1. atrial and ventricular aneurysms
  2. congestive heart failure
  3. post myocardial infarction syndrome(Dresslers syndrome)
  4. Arrythmias
  5. reinfarction

Internal Med (15 decks)

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